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HIGH YIELD FACTS

  • A brief resolved unexplained event (BRUE) is defined as “an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased, or irregular breathing; (3) marked change in tone (hyper- or hypotonia); and (4) altered level of responsiveness,” and a thorough history and physical examination which fails to identify an explanation.1,2

  • BRUE is a more specific term intended to replace ALTE (apparent life-threatening event)

  • BRUE is cohorted into lower- and higher-risk groups. Criteria for lower-risk include (1) age >60 days, (2) gestational age ≥32 weeks and postconceptional age ≥45 weeks, (3) a single episode with no previous BRUEs, (4) duration of BRUE <1 minute, (5) no cardiopulmonary resuscitation by trained medical personnel required, (6) no concerning historical features, and (7) no concerning physical examination findings.

  • Lower-risk BRUE infants generally do not require clinical investigations and can be discharged home from the emergency department (ED).

  • Most higher-risk patients, particularly those under 2 months of age, typically benefit from hospitalization for further monitoring for recurrent events, diagnostic evaluation, or treatment. In some cases, close outpatient follow-up may be reasonable.

  • BRUE is a diagnosis of exclusion just like another acute idiopathic condition of infancy, the febrile seizure. Both have lower- and higher-risk categories. The lower-risk groups of both of these conditions require few if any investigations and can be discharged from the ED.

A BRUE is “an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of ≥1 of the following: (1) cyanosis or pallor; (2) absent, decreased or irregular breathing; (3) marked change in tone (hyper- or hypotonia); (4) altered level of responsiveness.”1,2 It is diagnosed after a history and physical examination fails to find an explanation for the event. The term BRUE was recently proposed in a clinical practice guideline by an expert committee of the American Academy of Pediatrics.1,2 In this guideline, the committee recommends that BRUE replace ALTE (apparent life-threatening event) which had been in use since being proposed at a National Institutes of Health consensus conference in 1986.3

ALTE as defined is a symptom rather than a diagnosis.4 It encompasses a heterogeneous group of conditions potentially involving any body system. Because of the variability and non-specificity of ALTE, the risk for a subsequent or underlying disorder cannot be quantified.1 However, within the ALTE population is a benign, idiopathic group with negligible risk for recurrence. In these patients with no underlying cause of ALTE, in fact, the event was not “life-threatening.” The heterogeneity of potential conditions within ALTE undermined the quality of care and complicated the research of these infants. Therefore, a new term was needed to better describe these events. The BRUE practice guideline provides an approach to the evaluation and management of these infants and guides future research.

EVALUATION

A thorough history and ...

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